The nurse is assessing the patient's respirations. Which action by the nurse is most appropriate?
Inform the patient that she is counting respirations.
Do not touch the patient until completed.
Obtain without the patient knowing.
Estimate respirations.
The Correct Answer is C
A. Inform the patient that she is counting respirations:
This may lead the patient to alter their breathing pattern, making the result inaccurate.
B. Do not touch the patient until completed:
Touch is not contraindicated, and hand placement on the chest can assist in counting if needed.
C. Obtain without the patient knowing:
This is correct. Most accurate respiratory assessments are done while appearing to check pulse, to prevent voluntary changes in breathing.
D. Estimate respirations:
Estimating is not acceptable and may lead to inaccurate data that affects patient care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. 60:
This is the diastolic pressure, not the pulse pressure.
B. 80:
Pulse pressure = Systolic – Diastolic → 140 – 60 = 80. This is the correct calculation.
C. 140:
This is the systolic pressure, not the pulse pressure.
D. 200:
This is not a relevant value in this context and is mathematically incorrect.
Correct Answer is D
Explanation
A. Request an order for a urinalysis with culture and sensitivity:
There is no indication of infection (e.g., no cloudy urine, odor, or fever), so a C&S is not warranted at this point.
B. Irrigate the patient’s catheter using 60 mL of sterile normal saline:
Irrigation should only be done with a provider’s order or if there is a clear obstruction, which is not the case here.
C. Remove the catheter immediately and notify the health care provider:
Removing without an order or plan can put the patient at risk, especially with a spinal cord injury and potential retention issues.
D. Contact the health care provider for an order to change the catheter:
Long-term indwelling catheters are typically changed every 4 to 12 weeks to reduce infection risk and ensure function. This is the safest and most appropriate next step.
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